In literature, revisions are expected, even among the greats. Hemingway claims to have rewritten the final page of A Farewell to Arms 39 times before “getting the words right.” Rather than signifying failure, such revisions spell success. In plastic surgery, not so much. While every surgeon who operates with any regularity has a revision rate, do-overs are hardly a point of pride. Instead, they suggest dissatisfaction—or insinuate, perhaps, that mistakes were made.
While repeat plastic surgeries aren’t widely tracked or recorded in the same reliable fashion as primary procedures, the latest statistics report from the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) offers some rare insights. Revision surgery was the fourth most popular surgical procedure performed by its members last year, falling just behind the perennial chart-toppers: rhinoplasty, facelift, and blepharoplasty. The rate of revisions actually jumped an incredible 70% between 2020 and 2021, according to the organization.
Rhinoplasty is reputed to have the highest revision rate in the field, with numbers ranging up to–and even surpassing–20%, depending on the study you look at. Surgeons who specialize in nose jobs will, naturally, fall at the low end of the scale. New York City facial plastic surgeon Dr. Dara Liotta, for instance, who performs rhinoplasty almost exclusively, operating on between 5 and 15 noses per week, says she revises three or four of her own rhinoplasties annually.
She fields a far greater number of rhino-revision requests from her peers’ patients. “Revisions have definitely increased,” she says. “I’m seeing people who are seeking their third and fourth surgeries.” And she’s not alone. Board-certified Miami plastic surgeon Dr. Adam Rubinstein reports that, with revision cases in general, “more than half the time, it’s not just one operation [that a patient has had], it’s a couple or more.” Other surgeons shared similar anecdotes, attributing the revision spike to the overall surge in plastic surgery during the pandemic as well as elevated expectations and intensifying self-scrutiny on the part of patients.
Why patients seek plastic surgery revisions
While many surgeons classify all repeat surgeries as revisions, Dr. Johnny Franco, a board-certified plastic surgeon in Austin, Texas, believes a distinction should be made between true revisions—like those performed to correct legitimate problems—and secondary surgeries that are designed to enhance or augment an initial outcome. “There’s been a big boom in what I call round-two BBLs as social media continues to change patients’ aesthetic goals,” he says. “We sometimes have to do a multistage treatment, to safely achieve the look they want.”
Traditionally speaking though, plastic surgery patients have revisions for a few distinct reasons: They’re unhappy with the results of prior procedures; the benefits of those surgeries have simply run their course; or they’re aiming to amend actual complications.
Dr. David Sieber, a board-certified plastic surgeon in San Francisco specializing in high-definition liposuction, finds that his revision lipo patients fall into all three categories, with a large percentage enlisting his services after “realizing that the result they had [elsewhere] during their first round of lipo probably wasn’t as good as it should’ve been,” he notes.
Outcomes falling short of expectations—it’s a common theme among revision facelift patients too, says Dr. Laxmeesh Mike Nayak, a board-certified facial plastic surgeon in Frontenac, Missouri, and a champion of the deep plane lift. He frequently sees younger patients who were led to believe that a less invasive mini lift could sufficiently tackle early signs of aging—the deepening nasolabial folds, emerging jowls, and subtle slouchiness beneath the chin. As he explains, however, “all of those targets are really far forward in the face,” in territory rarely treated by mini lifts, which focus more on effecting change close to the ears, where incisions are made. “It’s much more palatable for people to sign up for a mini procedure, but then there’s a lot of dissatisfaction when they’re judging their result by: How are my jowls? Did I get a clean jawline way up front? And how’s the area under my chin looking?”
Dr. Nayak also routinely revamps facelifts that have aged over time—“people who had a great first facelift experience and now are ready to have that same pick-me-up again,” he says.
In the rhino realm, the classic revision seeker is one who got a nose job as a teen that didn’t wear well over time, Dr. Liotta says. These folks come to her, 10 or 20 years older, with a nose that is structurally unsound or has a dated aesthetic. “The goal, in most of those cases, is to make their noses look less operated on,” she says. Lately, she’s also seeing more patients “who had a pretty good nose to begin with” but, in attempting to fix a minor “flaw,” fell into “a spiral of bad advice and bad surgery and are now truly screwed up.”
The challenges of revision surgery
A primary operation, for better or worse, leaves a substantial footprint—morphing bone and cartilage, reconfiguring muscles and ligaments, upending blood flow, redistributing fat, and carving away skin. Even after the most meticulous surgery, your anatomy is no longer textbook. And unless the surgeon tasked with your revision also performed your first surgery, they’re essentially going in blind and attempting to solve a human puzzle—the rigors of which tend to be reflected in the procedure’s price tag.
“I often say, on a difficulty scale of 1 to 10, you can only get up to about a two with a primary rhinoplasty [in capable hands], because you have all the pieces that you came with,” says Dr. Liotta. “They may not be pretty or functional, but they’re all there.” With revisions, doctors are contending with the unknown. “You’d be shocked to see the anatomy that’s crazy disturbed or removed when the primary surgeon didn’t know what they were doing,” she adds.
Likewise, Dr. Nayak finds that the biggest factor impacting the difficulty or limitations of a revision facelift is how the tissues were handled the first time around. “If the SMAS was completely torn up and now resembles a moth-eaten structure or a piece of Swiss cheese, it’s going to be hard for me to lift that muscular layer and count on it to do very much,” he says. Along the same lines, when previous procedures have thoroughly decimated someone’s superficial fat, making the face appear soft—not skeletal—becomes a monumental feat.
As with any kind of injury, surgery also ignites an enormous healing response in the body, complete with swelling and scar tissue formation, which can complicate future operations. While some folks are genetically programmed to produce an abundance of scar tissue post-op, a poorly executed surgery can also ramp up internal scarring, leaving the tissues firm and impliable. “I did a lipo revision the other day that was just horrific, with scar tissue everywhere,” says Dr. Sieber. “In these cases, it’s literally impossible to get a great result, because the tissue is ruined—it’s like I’m pushing my cannula against a brick.”
Indeed, says Dr. Rubinstein, “every surgery adds to the scar tissue and the technical considerations of what can be done next.” And that’s assuming the initial operation went off without a hitch. When serious complications arise from a primary procedure, infection, tissue loss, and scarring can muddle the landscape even more, making it harder to adequately restore someone in a single revision, notes Dr. Rubinstein. (The new Lifetime series My Killer Body spotlights some of the more disastrous cases he’s been called on to fix.) Regardless, he adds, “an experienced surgeon can look at a problem and have a very good idea of what can be accomplished reliably, in a safe manner, and what might be stretching it.”
The rise of the nonsurgical revision
Here’s a twist in the revision genre: our experts say they’re frequently taking patients to the OR to rectify subpar results imparted by nonsurgical interventions. Many of the modalities they mentioned—powerful energy-based devices, in particular—can traumatize the tissues of the face and body, making primary surgery every bit as challenging as a revision.
“I call it the stealth revision,” says Dr. Nayak. While these patients have never gone under the knife, they no longer possess virgin tissues, so surgeons consider them revision candidates.
Dr. Nayak points out that technologies that work under the skin, like Renuvion, FaceTite, and certain RF needling tools, have the potential to heat the tissues to such a degree that they can impair circulation to the skin—in addition to robbing fat and creating scar—all of which boosts risks during subsequent facelifts. “It’s really important to disclose to your surgeon which procedures you’ve had, how many times, and when,” he says. “If someone has had one of these treatments relatively recently and fairly aggressively, I’m going to tell them to delay facelift surgery until the injured capillary bed can recover,” in hopes of avoiding skin-flap complications.
In Dr. Sieber’s body-focused practice, paradoxical adipose hyperplasia (PAH) has become more prevalent among patients who’ve tried CoolSculpting prior to seeking lipo. (PAH is the condition supermodel Linda Evangelista claims to have suffered following several rounds of fat-freezing; it occurs when fatty areas expand rather than shrink following treatment.) Dr. Sieber sees a handful of people each month who either have “true PAH, where we can see the outline of the applicator in their skin,” or some amount of scar tissue from the treatment. “When I meet these patients now, I’m really honest with them. I’ll say, ‘Listen, you’re not here for routine liposuction—you’re having reconstructive surgery.’” These lipo outcomes tend to be less predictable, he adds, and are more prone to contour irregularities and scarring.
Perhaps the most devastating example of nonsurgicals gone sideways is illegal butt shots. “Someone goes in thinking they’ll just get some easy injections, have a fuller butt, and be happy,” says Dr. Rubinstein. “But over time, the body reacts to the foreign material by basically turning the surrounding tissue to stone, creating this horrific problem that requires patients to have several operations just to get pain-free.”
The 6 rules of revision surgery
Whether your first procedure was surgical or nonsurgical in nature, involving the face or body, your revision will be a uniquely different experience. Here’s how to navigate it.
1. Don’t rush to revise
Plastic surgeons customarily advise putting a year between a primary surgery and a revision, to allow swelling to subside, tissues to soften, and scars to mature. “Rushing back too fast can be a setup for more problems,” warns Dr. Franco. “Things change a lot over time—and we don’t want to be trying to hit a moving target.”
But there are exceptions to every rule. Surgeons who are less strict about the timeline give equal weight to the severity of the patient’s problem, the state of their tissues, and the person’s psychological well-being. “A year would be great—and I do think it’s ideal—but you have to remember that some revision patients are living with really deforming problems,” says Dr. Rubinstein. “I’ve done revisions as early as three months—when the fix is simple and there’s plenty of tissue and everything is healed and soft.” On the flip side, he adds, in cases of extended healing, it’s not unheard of to wait two years or more before reoperating.
Dr. Liotta admits to being heavily influenced by patients’ emotional distress. In certain circumstances, “if the problem is really bad and they beg me hard enough, maybe I’ll do it at 10 months,” she says. She’s more likely to operate before the one-year mark on people with thinner skin—they tend to heal faster than those with thicker skin—particularly if they have a major structural issue that is never going to improve on its own, she says.
A critical caveat: If a patient is so distraught that “they can’t have a rational discussion about their situation, because they’re still too blinded by disappointment, rage, or fear,” Dr. Rubinstein says, then surgeons may suggest postponing revisions, to allow more time for emotional healing.
2. Check in with your primary surgeon
There are clear advantages to having your primary surgeon do your revision. For starters, “they’re going to have the most intimate knowledge of what’s going on—and will likely have a good idea of how to address it,” says Dr. Franco. Another perk: most reputable plastic surgeons don’t charge to revise their own work, Dr. Liotta tells us.
If you had a bad experience with your doctor or have come to realize that their creds aren’t up to snuff, make a change though—no matter the cost. The surgeon performing your revision should not only be board-certified in plastic surgery, facial plastic surgery, or, if you’re having your eyes done, oculoplastic surgery, but they should be a proficient fixer. “You should not have a revision by a surgeon who doesn’t do a ton of them,” insists Dr. Liotta. And don’t be shy about asking for proof. If you’re having a revision rhino, for example, “a good surgeon should be able to produce many photos—including long-term, fully healed afters—of noses with a problem like yours.”
3. Adjust your expectations
When assigned an imperfect medium, like adulterated human tissue, surgeons can’t promise a flawless result. That said, some procedures allow them to come closer than others. A secondary breast augmentation undertaken to go bigger is infinitely more straightforward than, say, a revision rhinoplasty, where there’s greater room for error.
“Every time you have surgery on your nose, my ability to make a really big change and head toward perfection decreases by half,” explains Dr. Liotta. So after a revision, “your nose is going to be better, but it’s definitely not going to be perfect,” she says. “And I make it my job to say this three times during every revision consult—and to always use the word ‘definitely.’”
With repeat facelifts, the outlook may be brighter, since the face offers more opportunity than the confines of the nose—but again, there are no guarantees. “With some of my revision facelifts, I’m able to leapfrog over the area that was messed with in round one to where there’s good or even virgin tissue remaining,” says Dr. Nayak. Still, plenty of patients come with strikes against them—whether the tissues were mishandled or they’ve merely aged a decade since the first lift—and the forecast worsens with each additional hit, he notes.
“It’s important for revision patients to temper their expectations and have realistic ideas of what can be accomplished,” says Dr. Rubinstein.“Part of the heartbreak of a bad first result is coming to terms with the fact that you might never have the outcome you initially envisioned.”
4. Set clear and specific goals
When meeting with a surgeon about a revision, express precisely what it is that bothers you about your original result, avoiding generalities. Your surgeon will want to hear about one or two very specific things that you’re hoping to change. Remember: Perfection is off the table; you’re setting new measures of success.
Dr. Franco finds that photos are helpful for communicating goals and ensuring that visions align—particularly when revising BBLs and breast surgeries, where size matters. “The hardest thing is making sure that what they’re picturing is something I can obtain,” he says.
Your surgeon should also point out any cosmetic or structural issues that cannot be improved because they’re related to scarring, healing, or other forces outside the surgeon’s control. “If you have skin laxity, for instance, there’s going to be a limit as to how much tighter I can make your breasts or tummy,” Dr. Franco says. If a failed tummy tuck left a wide, lumpy scar, it may be impossible to remove it all at once without creating another faulty incision line.
5. Ask about the risks of revision surgery
Revisions carry all the risks of primary surgery—and then some. The specifics depend on the procedure. With tummy tucks and breast lifts, says Dr. Franco, “we can start affecting blood supply to areas when we’re doing multiple revisions”—hiking the possibility of tissue death.
This tends to be less of an issue with revision facelifts, notes Dr. Nayak. The primary danger there is a heightened risk of nerve damage in cases where the once neatly organized layers of the face were obliterated, leaving surgeons without the normal anatomical landmarks that typically guide them to safe zones and depths.
The most pivotal and universal risk of revision surgery is unpredictable healing. While post-op healing is always a biological crapshoot, revision rhino exemplifies the biggest gamble, according to every surgeon we spoke to. “Nose surgery is especially unpredictable in healing,” Dr. Rubinstein says. “It takes only a tiny amount of internal scar tissue to create a bump or irregularity—it’s very frustrating and completely uncontrollable.”
This is what revision rhino specialists dread most—having a new and unexpected blip develop during recovery, Dr. Liotta says. As she explains it, healing ultimately comes down to swelling resolution, which hinges upon your lymphatics recovering and getting back to the business of draining fluid. This process slows with each surgery. “And the longer you’re swollen, the longer there are inflammatory cells floating around and the more likely you are to form scar tissue, which thickens the skin and risks distorting your result,” she says.
In short, she adds, “you just don’t heal as well from revision surgeries.”
6. Prepare for a lengthy recovery
Rebounding from revision surgery is rarely a cakewalk—save for, perhaps, breast aug patients. These unicorns often find recovery to be breezier the second or third time around, Dr. Rubinstein tells us. “Because the [implant] pocket has already been made and there’s typically less manipulation of the muscle,” they tend to have minimal pain and swelling. There’s also an element of been-there-done-that, he says, which makes the whole process more manageable.
Of course, if someone has aged significantly between surgeries, they may notice that they’re slower to heal, regardless of the type of procedure.
In truth, longer-than-average recoveries are the norm with revisions. Take lipo: while first-timers can expect to look pretty good at three months and see real results around six months, Dr. Sieber braces his revision and PAH patients for a much longer road. “It’ll be a year or two before they see final results, because they’re more likely to have prolonged swelling and more scar tissue,” he says. Which makes post-op care extra crucial. “They may need to wear compression for longer or have additional lymphatic drainage massages,” he notes, to counter common complications like seroma (fluid buildup), contour irregularities, and fibrosis.
Also not a picnic: the recovery from—you guessed it—a revision nose job. “You’re not going to like your nose for three months,” Dr. Liotta warns—that’s the absolute earliest you can judge the outcome. And again, you could be waiting upwards of two years for your new nose to completely materialize. “It’s a very emotional process in so many ways,” she adds, as patients are battling both the anxiety bred by yet another uncertain result as well as the guilt that often comes with spending money on elective procedures and taking time away from work and family.
Across the board, revision surgery can be physically, mentally, and financially draining, especially if you go in unprepared. But if you partner with the right plastic surgeon and give yourself time to recover, “there is hope for just about any problem we encounter,” Dr. Rubinstein says. “Sometimes we really do give people their lives back.”
